Behind elevated hospitalisation rates: addressing racism in the medical system
Authors: Robert Hogg, Megan Marziali
Journal: The Lancet Public Health (2023)

The Article by Sophia Rein and colleagues,1Rein SM Lampe FC Ingle SM et al.All-cause hospitalisation among people living with HIV according to gender, mode of HIV acquisition, ethnicity, and geographical origin in Europe and North America: findings from the ART-CC cohort collaboration.Lancet Public Health. 2023; 8: e776-e787Google Scholar published in The Lancet Public Health, provides ample evidence that substantial disparities exist in all-cause hospitalisation among people with HIV in high-income countries in Europe and North America. The authors examined hospitalisation rates among 23 594 people with HIV in Europe and 9612 in North America. In North America, hospitalisation rates were highest among Black and African American and Indigenous people with HIV, similar to rates reported in 2021 by the NA-ACCORD in Canada and the USA.2Davy-Mendez T Napravnik S Eron JJ et al.Racial, ethnic, and gender disparities in hospitalizations among persons with HIV in the United States and Canada, 2005–2015.Aids. 2021; 35: 1229-1239Crossref Scopus (1) Google Scholar Although the study by Rein and colleagues1Rein SM Lampe FC Ingle SM et al.All-cause hospitalisation among people living with HIV according to gender, mode of HIV acquisition, ethnicity, and geographical origin in Europe and North America: findings from the ART-CC cohort collaboration.Lancet Public Health. 2023; 8: e776-e787Google Scholar reports on higher rates of hospitalisation across various sociodemographics, such as people who use injection drugs, women, and Black people, we focus here on the elevated hospitalisation rates among Indigenous people. The Truth and Reconciliation Commission of Canada recognised that poor health outcomes among Indigenous People in Canada are rooted in the ongoing and lasting effects of colonisation.3Truth and Reconciliation Commission of CanadaHonouring the truth, reconciling for the future: Summary of the final report of the Truth and Reconciliation Commission of Canada. Truth and Reconciliation Commission of Canada, Ottawa, ON2015Google Scholar Residential schools, a purported educational system operated by the Government of Canada, forcibly separated Indigenous children from their homes with the explicit goal of assimilation into White Canadian culture.4Truth and Reconciliation Commission of CanadaCanada's residential schools: the history, part 2 1939 to 2000. Truth and Reconciliation Commission of Canada, Ottawa, ON2015Google Scholar More than 150 000 children were forced to attend school, in which one in 25 children died before graduating.3Truth and Reconciliation Commission of CanadaHonouring the truth, reconciling for the future: Summary of the final report of the Truth and Reconciliation Commission of Canada. Truth and Reconciliation Commission of Canada, Ottawa, ON2015Google Scholar Residential schools are very recent history, as the last school did not close until the late 1990s.4Truth and Reconciliation Commission of CanadaCanada's residential schools: the history, part 2 1939 to 2000. Truth and Reconciliation Commission of Canada, Ottawa, ON2015Google Scholar The legacies of residential schools and racism in Canada can be seen in the disproportionate burden of hospitalisations among Indigenous People, especially those due to endocrine, nutritional, and metabolic diseases and mental health conditions.5Bougie E Acute-care hospitalizations among First Nations people, Inuit and Métis: results from the 2006 and 2011 Canadian Census Health and Environment Cohorts.Health Rep. 2021; 32: 11-26Google Scholar Racism against Indigenous people persists in the health-care setting, functioning to limit access to medical treatment, thus negatively affecting health and wellbeing.6Turpel-Lafond M In plain sight: addressing Indigenous-specific racism and discrimination in BC Health Care.https://engage.gov.bc.ca/app/uploads/sites/613/2020/11/In-Plain-Sight-Summary-Report.pdfDate: 2020Date accessed: September 7, 2023Google Scholar A report from British Columbia, Canada, revealed pervasive stereotyping in the health-care setting.6Turpel-Lafond M In plain sight: addressing Indigenous-specific racism and discrimination in BC Health Care.https://engage.gov.bc.ca/app/uploads/sites/613/2020/11/In-Plain-Sight-Summary-Report.pdfDate: 2020Date accessed: September 7, 2023Google Scholar The report suggests that Indigenous patients are viewed as less worthy of care and that they exhibit drug-seeking behaviours, are frequent flyers, or are seen as irresponsible and non-compliant with treatment.6Turpel-Lafond M In plain sight: addressing Indigenous-specific racism and discrimination in BC Health Care.https://engage.gov.bc.ca/app/uploads/sites/613/2020/11/In-Plain-Sight-Summary-Report.pdfDate: 2020Date accessed: September 7, 2023Google Scholar As a result of this derogatory and discriminatory stereotyping, Indigenous people experience harm, poor quality of care, and even death through the denial of services, long wait times, minimisation of concerns, inappropriate pain management, or an absence of respect for cultural protocols.6Turpel-Lafond M In plain sight: addressing Indigenous-specific racism and discrimination in BC Health Care.https://engage.gov.bc.ca/app/uploads/sites/613/2020/11/In-Plain-Sight-Summary-Report.pdfDate: 2020Date accessed: September 7, 2023Google Scholar There are approximately 6200 Indigenous People living with HIV in Canada, which is 10% of the total number of people living with HIV in this country; Indigenous People accounted for 14% of new infections in 2018.7Public Health Agency of CanadaEstimates of HIV incidence, prevalence and Canada's progress on meeting the 90-90-90 HIV targets, 2020. Public Health Agency of Canada, Ottawa, ON2022Google Scholar The proportion of the population self-identifying as Indigenous in Canada is approximately 5·0%, as of the 2021 census, solidifying that Indigenous People are overrepresented among the population of people with HIV. On the basis of limited data, the uptake of antiretroviral therapy is quite poor in Canada as well.7Public Health Agency of CanadaEstimates of HIV incidence, prevalence and Canada's progress on meeting the 90-90-90 HIV targets, 2020. Public Health Agency of Canada, Ottawa, ON2022Google Scholar Little is known about Indigenous hospital trends among people with HIV in Canada, except what has been reported by the Antiretroviral Therapy Cohort Collaboration and NA-ACCORD.1Rein SM Lampe FC Ingle SM et al.All-cause hospitalisation among people living with HIV according to gender, mode of HIV acquisition, ethnicity, and geographical origin in Europe and North America: findings from the ART-CC cohort collaboration.Lancet Public Health. 2023; 8: e776-e787Google Scholar, 2Davy-Mendez T Napravnik S Eron JJ et al.Racial, ethnic, and gender disparities in hospitalizations among persons with HIV in the United States and Canada, 2005–2015.Aids. 2021; 35: 1229-1239Crossref Scopus (1) Google Scholar The identification of higher rates of hospitalisations within sociodemographic groups, as done by Rein and colleagues,1Rein SM Lampe FC Ingle SM et al.All-cause hospitalisation among people living with HIV according to gender, mode of HIV acquisition, ethnicity, and geographical origin in Europe and North America: findings from the ART-CC cohort collaboration.Lancet Public Health. 2023; 8: e776-e787Google Scholar is a key step in understanding and addressing health disparities. As insightfully noted by the authors, sociostructural factors and barriers could impede routine health-care uptake and affect long-term health outcomes; here, we highlight the role that racism plays as a barrier to care. Addressing higher rates of all-cause hospitalisations among Indigenous people means addressing the underlying sociostructural factors resulting from colonialism and intergenerational trauma. Research in British Columbia suggests that childhood maltreatment resulting from colonial harms, leading to intergenerational trauma, is associated with drug-related HIV and hepatitis C virus incidence,8Pearce ME Jongbloed K Pooyak S et al.The Cedar Project: exploring the role of colonial harms and childhood maltreatment on HIV and hepatitis C infection in a cohort study involving young Indigenous People who use drugs in two Canadian cities.BMJ Open. 2021; 11e042545Crossref Scopus (1) Google Scholar substance use, and poor mental health outcomes.9First Nations Health AuthorityOverdose data and First Nations in BC: preliminary findings. First Nations Health Authority, West Vancouver, BC2017Google Scholar This lasting trauma, coupled with ongoing experiences of racism within the health-care system, could work synergistically to reinforce distrust in the medical system, which impedes and prohibits appropriate and regular medical care. Public health emergencies, such as the drug toxicity crisis, function to accentuate the flaws in a system by showing who is overburdened by negative health outcomes. Indigenous people are more likely to die from a drug overdose and experience a non-fatal overdose than people who are not Indigenous.9First Nations Health AuthorityOverdose data and First Nations in BC: preliminary findings. First Nations Health Authority, West Vancouver, BC2017Google Scholar Preliminary data suggests that women with HIV have the highest burden of non-fatal overdoses, as measured by contact with the health-care system, which could also reflect higher rates of hospitalisations in this group;10Marziali ME, Kooij KW, Trigg J, et al. Sex differences in non-fatal overdoses: a population-based cohort study. Conference on Retroviruses and Opportunistic Infections; Feb 19–22, 2023 (abstr 858).Google Scholar Indigenous women are 8 times more likely to experience an overdose event than non-Indigenous women.9First Nations Health AuthorityOverdose data and First Nations in BC: preliminary findings. First Nations Health Authority, West Vancouver, BC2017Google Scholar Further, Indigenous women and girls are particularly affected by Indigenous-specific racism in the health-care setting.6Turpel-Lafond M In plain sight: addressing Indigenous-specific racism and discrimination in BC Health Care.https://engage.gov.bc.ca/app/uploads/sites/613/2020/11/In-Plain-Sight-Summary-Report.pdfDate: 2020Date accessed: September 7, 2023Google Scholar Despite a large body of evidence showing racism affects health, little has been done to change this shameful pattern. Here we have discussed the effect of racism on Indigenous People in Canada. Addressing racism in medical settings and taking tangible steps to improve health outcomes among minoritised groups is crucial for decreasing hospitalisation rates. MM is supported by the National Institute on Drug Abuse (T32DA031099). RH declares no competing interest. All-cause hospitalisation among people living with HIV according to gender, mode of HIV acquisition, ethnicity, and geographical origin in Europe and North America: findings from the ART-CC cohort collaborationSubstantial disparities exist in all-cause hospitalisation between demographic groups of people living with HIV in the current cART era in high-income settings, highlighting the need for targeted support. Full-Text PDF Open Access